Руководство поставщика


The Department of Human Services (DHS) has mandated minimum requirements for Medical Assistance to ensure that Carelon and Carelon providers are preventing and detecting potential fraud, waste and abuse (FWA). 

  • Fraud: Any type of intentional deception or misrepresentation made with the knowledge that the deception could result in some unauthorized benefit to the person committing it or any other person. The attempt itself is fraud, regardless of whether or not it is successful.
  • Потери: Включает чрезмерное использование услуг или другие методы, которые прямо или косвенно приводят к ненужным расходам. Обычно считается, что потери не вызваны преднамеренными действиями, а возникают, когда ресурсы используются не по назначению.
  • Злоупотребление: Когда поставщики или поставщики медицинских услуг не следуют надлежащей медицинской практике, что приводит к ненужным или чрезмерным затратам, неправильной оплате, неправильному использованию кодов или услугам, которые не являются необходимыми с медицинской точки зрения.

In the Pennsylvania HealthChoices Behavioral Health Program Standards and Requirements, Appendix F obliges Carelon and Carelon providers to comply with Federal and State regulations and implement compliance programs and efforts that prevent and detect fraud, waste, and abuse. Subsequently, Carelon has implemented a FWA plan with policies and procedures, trainings, and reporting responsibilities, as outlined on the Carelon Веб-страница о мошенничестве и злоупотреблениях. Minimum documentation standards for payment are outlined on the Services webpage at Минимальные стандарты документации.

Следственный процесс

The Special Investigations Unit (“SIU”) investigates suspected incidents of FWA for all types of services. Carelon may take corrective action with a Provider or Facility, which may include, but is not limited to:

  • Written warning and/or education: Carelon sends letters to the Provider or Facility advising the Provider or Facility of the issues and the need for improvement. Letters may include education, requests for repayment or may advise of further action.
  • Medical record review: Carelon reviews medical records to investigate allegations or validate the appropriateness of Claims submissions.
  • Edits: A certified professional coder or investigator evaluates Claims and places payment or system edits in Carelon’s Claims processing system. This type of review prevents automatic Claims payments in specific situations.
  • Recoveries: Carelon recovers overpayments directly from the Provider or Facility. Failure of the Provider or Facility to return the overpayment may result in reduced payment for future Claims, termination from our network, or legal action.

Политики и процедуры

Carelon has established policies and procedures to meet the DHS requirements specific to the prevention and detection of fraud, waste, and abuse (FWA). All Carelon providers are responsible to meet the requirements on the Carelon Fraud and Abuse webpage.

Обязательные тренинги

All providers are required to complete the Interactive Fraud, Waste and Abuse Training offered by Carelon on an annual basis. The provider or provider representative is responsible for reporting all information to the provider and/or the entire staff of the provider agency. Providers are responsible for maintaining documentation of training completion. Training can be accessed via the Веб-страница обучения поставщиков услуг or the Веб-страница о мошенничестве и злоупотреблениях.

All new providers are responsible to review the Carelon Веб-страница о мошенничестве и злоупотреблениях and the Минимальные стандарты документации.

Составление отчетов

All providers are required to report suspected fraud and abuse. If someone suspects any Member (a person who receives benefits) or Provider has committed fraud, waste or abuse, they have the right to report it. No individual who reports violations or suspected fraud and abuse will be retaliated against for doing so. The name of the person reporting the incident and his or her callback number will be kept in strict confidence by investigators.

Сообщить о проблемах:

Any incident of fraud, waste or abuse may be reported to Carelon anonymously; however, Carelon’s ability to investigate an anonymously reported matter may be limited if Carelon doesn’t have enough information. Carelon encourages Providers and Facilities to give as much information as possible. Carelon appreciates referrals for suspected fraud but be advised that Carelon does not routinely update individuals who make referrals as it may potentially compromise an investigation. Learn more at www.fighthealthcarefraud.com.

The Department of Human Services has established a hotline to report suspected fraud, waste, and abuse committed by any entity providing services to Medical Assistance recipients. The hotline number is 1-866-DHS-TIPS (1-844-347-8477) and is available between the hours of 8:30 AM and 3:30 PM, Monday through Friday. Voice mail is available at all other times. Callers do not have to give their name and may call after hours and leave a voice mail if they prefer.

Some common examples of fraud, waste and abuse are:

  • Выставление счетов или взимание платы с получателей медицинской помощи за покрываемые услуги
  • Выставление счетов более одного раза за одну и ту же услугу
  • Отпуск непатентованных препаратов и выставление счетов за оригинальные препараты
  • Falsifying records
  • Оказание ненадлежащих или ненужных услуг

Suspected fraud, waste and abuse may also be reported via the website at: https://www.dhs.pa.gov/about/Fraud-And-Abuse/Pages/MA-Fraud-and-Abuse—General-Information.aspx

You do not have to give your name if you use the website or email to report fraud, waste or abuse. The website contains additional information on reporting fraud, waste and abuse